Get Cape Cod Healthcare Dpo Medical Plan Medical Exception Form

Filling out the Cape Cod Healthcare DPO Medical Plan Medical Exception Form online is a straightforward process. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the medical exception form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide patient information by filling in the patient's name, date of birth, address, city, state, ZIP code, phone number, and Tufts member ID.
3. Indicate whether the primary care provider (PCP) is a DPO provider by circling 'Yes' or 'No.' Then, enter the PCP's name, phone number, and fax number.
4. Specify the provider or facility you are requesting an exception for by selecting the type of service (office visit, lab services, radiology/imaging) and filling in the provider or facility's name, date(s) of service, specialty, NPI number, address, city, state, ZIP code, phone number, and fax number.
5. Answer whether you have previously been seen or treated by this provider/facility. If 'Yes,' include the date you were last seen.
6. Select the reason for your request from the provided options, and provide a description of the service requested.
7. Complete the authorization section by adding your signature and the date.
8. Once all fields are completed, you can save the changes, download the form, print it, or share it as needed.

Complete your documents online and ensure your medical exception requests are submitted efficiently.